47 year old male with altered sensorium fever headache

" This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box are welcome." 

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

(I ve made this blog with help of https://08arshewarpavankumar.blogspot.com/)

 • Courtesy video amd image references 

Time line of events - 

■1997  :patient married at 22 years 

■1998: he started smoking and drinking on occasional purposes

■1998-2000: he had two sons and one of the son died due to dog bite following which alcohol consumption was more

■ 2000-2022 : uneventful patient was alright without any complaints

■ 2022, 24th march : 

Patient was apparently asymptomatic 3 days back then developed high grade fever with  chills, intermittent and relieved with meds and associated with severe headache since 3 days ,throbbing in nature

Not associated with burning micturition , vomiting's, loose stools, sob, cough , chest pain, bleeding manifestations

There are complaints of altered sensorium since 3 hours unable to talk and walk properly so was brought to casualty on 24th march

No urine output since morning

CHIEF COMPLAINTS:

Patient came to the hospital with the chief complaints of - fever , headache , altered talking ,walking n confusion.

HOPI:

Patient was apparently asymptomatic 5days back .Then developed-

 High grade fever with chills, intermittent in nature, relieved on medication and was associated with  headache.

Altered sensorium since 2 to 3 hours (not talking and not working properly).

No urine output since morning on 24-3-22

No history of  burning micturition,  vomiting, loose stools,  SOB,  cough ,chest pain, bleeding manifestations.

PERSONAL HISTORY

DIET-mixed

Appetite-decreased 

Sleep-inadequate

Bowel-regular

Bladder - decreased

PAST HISTORY:

N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy

ADDICTIONS:

Smokes ,montly once and was a occasional drinker but stopped 1 month back.

GENERAL EXAMINATION: 

Patient is oriented to time ,place and person

No Pallor /Icterus /Cyanosis/clubbing/Edema of feet  /Lymphadenopathy.

VITALS :  

Temp :  101  F 

PR : 90 bpm

BP : 140/80 mmhg 

RR : 18 

SPO2 : 98 % at RA 

GRBS-122 mg/dl

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  S1 and S2 heard, no murmurs heard .

RESPIRATORY SYSTEM : Bilateral air entry present ,  clear .

PA : soft and non tender

CNS:

GCS-

E4V3M6, 

pupils- B/L NSRL

HIGHER MENTAL FUNCTIONS:

Oriented to time,place,personMemory : immediate,recent, remote intactSpeech: normalNo delusions or hallucinations

CRANIAL NERVES: 

1- intact

2- not tested

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

 

7- normal

8- Normal hearing

9,10- No difficulty in swallowing and speech, gag reflex not tested

11,12- normal.

MOTOR SYSTEM EXAMINATION :

TONE:  normal

POWER :                    Right       Left

     

    Upper limb          5/5             5/5

    Lower limb          5/5             5/5

Reflexes :                 Right                Left

1. Biceps:              2+                      2+
2. Triceps:            2+                      2+
3. Supinator:      2+                      2+
4. Knee:                2+                       2+
5. Ankle:               2+                        2+

Plantars:            extensor          Flexor

Babinski - negative

Meningeal signs-

Neck stiffness -present 

Kernigs sign - positive

SENSORY EXAMINATION:

Normal

CEREBELLUM EXAMINATION:

Able to do finger nose test. Dysdiadokinesia presentNo rebound tenderness Gait: could not be elicited

AUTONOMIC NERVOUS SYSTEM:

No abnormal sweatingNo resting tachycardia

MRI Impression (24-3-22)

- Few lacunar infarcts in medulla on left side.No f/o raised ICT on MRI 

Chest x-ray (24-3-22)

Ultrasound report (24-3-22)

ECG

Opthal- fundoscopy i/v/o any raised ICT for  LP

Blood culture report (26-3-22)

Urine culture report(26-3-22)

Fever charting

TREATMENT: 

On 24-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS

INJ. MONOCEF 2 GM IV BD

INJ. DEXA 8 MG IV STAT

TAB DOLO 650 MG RT/SOS

BP,PR monitoring 4 th hourly

On 25-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS if temp >101°F

INJ.Thiamine 1 amp in 100ml NV/IV/OD

INJ. MONOCEF 2 GM IV BD

INJ. DEXA 4 MG IV STAT

INJ DOXY 100 mg IV BD

Strict  I/O charting

W/f seizure activity

INJ. Vancomycin 2mg IV stat

INJ.Optineuron 1amp + 500ml NS over 1hr

BP,PR monitoring 4 th hourly

On 26-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS

INJ.Thiamine 1 amp in 100ml NV/IV/OD

INJ. MONOCEF 2 GM IV BD

INJ. DEXA 4 MG IV STAT

INJ DOXY 100 mg IV BD

TAB DOLO 650 pO TID

Strict  I/O charting

W/f seizure activity

INJ. Vancomycin 1mg IV BD

INJ.Optineuron 1amp + 500ml NS over 1hr

BP,PR monitoring 4 th hourly

On 27-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS

INJ.Thiamine 200mg IV BD

INJ. MONOCEF 1 GM IV BD

INJ. DEXA 4 MG IV BD

INJ DOXY 100 mg PO BD

TAB DOLO 650 pO TID

Strict  I/O charting

W/f seizure activity

INJ. Vancomycin 1mg IV BD

INJ.Optineuron 1amp + 100ml NS over 1hr

BP,PR monitoring 4 th hourly.

LP done on 24-3-22 at 2 am - showing around 450 cells? Lymphocyte predominant,

Glucose - 32

Protein - 195

Chloride - 120

 GRBS at time of LP - 112mg/dl

Provisional diagnosis- meningitis

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. 

This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

( All the information have been collabated from patient).

Case discussion;

Following is the view of my case

Case discussion ;

A 58 old male daily wage labourer by occupation came to the hospital .

Chief complaints ; shortness of breath since 1 month.

Decreased urine out put since 1month

Pedal edema since 3 months

Chest pain since 1 month

Facial puffiness since 1 month

History of present illness;

The patient was alright 4 years ago

4 years ago - pt complained of giddiness, went to a local hospital and was diagnosed as Hypertensive, on regular medication since then T. Nicardia 10mg, T. Arkamine 0.1mg sos

2 years back Pt developed B/L pedal edema, progressed gradually to knees, diagnosed with renal failure and initiated dialysis weekly twice

Left upper limb swelling, gradually progressing to current size, since 4 months .

Also developed rt upper limb swelling since 4 days.

 Swelling in the left chest region, gradually progressing to current size, since 4 months

Back pain since 2 months, subsided on medication (T. Ultracet)

30 days back - developed

Shortness of breath ,

Grade II-III progressed to Grade IV since 30 days along with orthopnea .

Sob worsened 1day back, associated with dragging type of chest pain .came for dialysis last night.

Even after dialysis, chestpain did not subside

Ecg was done(18/01/22): ST elevations noted in V2,V3,V4

Repeat ecg done (on 19/01/22): 

ST elevations subsisded

C/o. generalized body pains

No c/o palpitations, giddiness, cold, cough, burning micturition

PAST HISTORY -

Known case of Hypertension since 4years on Tab nicardia 20mg OD

Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history:

Appetite- decreased

Diet- mixed

Bowel movement- Regular

Alcoholic stopped 4 yrs ago

Non smoker

On examination:

Pt is C/c/c

No Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy

B/L pedal Edema(pitting type) present

Vitals

Pr:94bpm

Bp:120/80

Spo2:97% at RA

Temp - Afebrile

Systemic examination

CVS - S1,S2 +

RS - BAE + 

CNS - NAD

P/A- Soft, non tender

Pleural fluid LDH 98

Serum LDH 294

Ratio-0.3

Pleural fluid protein-2.0

Serum total protein -5.9

Ratio-0.3

Total count -100cells

Differential count- 

80% lymphocytes

20% neutrophils

Transudative effusion

Provisional Diagnosis -

CKD on MHD

Heart failure secondary to coronary artery disease(recent lateral wall MI)

?Spondylodiscitis

Hypertensive since 4yrs

?left upper limb lymphedema (secondary to AV fistula surgery)

Treatment ;

✓ fluid restriction 1.5 litre/ day

✓ salt restriction <2g/day

✓ tab lasix 40mgbd

✓tab metoz 5mg of

✓ tab nicardia 20mgbd

✓ tab arkamine 0.1 mg TID

✓ tab orofer-xt of

✓ tab nodosis 500mg bd

1-*-1

✓ tab shelcal 500mg of *-1-*

✓cap bioD3 0.25 mg of

✓ tab pan-d 40mg of

✓inj erythropoietin 4000u sc once weekly

✓ moniter vitals

55 YEAR OLD MALE WITH GIDDINESS AND LETHARGY

55Y/M with Giddiness and lethargy

55 year old male painter by occupation came to casualty with cheif complaints of 

1.Giddiness since 2 days

2.lethargy since 1 day

- Patient was apparently alright 2 days back then at 9:00 am he had sudden episode of giddiness while urinating in the bathroom where he fell down on his knees, no LOC,No involuntary movements of UL/LL.

- He was taken to outside hospital found out to be having BP-250/120mm of hgand so  antihypertensives were given.

- from  day 1 patient was brought  here with lethargy,  decreased responsiveness for further evaluation.

- On presentation to casualty , he had 

 BP: 180/120mm hg f/b 170/100 f/b 160/100 and 150/80 mm hg.

Past history:

K/C/O HTN since 2 years and on irregular medication,

~Not a K/C/O DM, Bronchial asthma,CAD.

Family History

No family history of HTN, DM, bronchial asthma, epilepsy.

General examination:- 

- Patient is conscious,coherent, cooperative,oriented to time,place and person.

- No signs pallor,icterus,cyanosis,lymphadenopathy&pedal edema

Vitals:

Temp:- 98.3 F

BP:- 180/120 mmhg

RR:- 20 cpm

PR:- 72 bpm

Systemic examination:-

CVS- S1, S2 heard,

RS:BAE present

CNS: 

          TONE      UL     LL

          Right   Normal Normal

          Left     Normal Normal

          POWER    UL    LL

           Right       4/5   4/5

           Left          4/5   4/5

           

        REFLEXES

                           RIGHT LEFT

              B              +         + 

              T              +         +

              S             +          +

              K             +          +

              A             +          +

              P           Flexion Flexion

Gait: https://youtu.be/-uRgLAvGvPc

Investigations:

MRI BRAIN(PROVISIONAL):

Impression:

1.Acute infarct in putamen,globus pallidus on RT side which shows blooming on SWI-Likely Hemorrhagic transformation

2.Old infarct in left side of pons

3.B/L periventricular hyperintensities on T2/FLAIR-S/O small vessel ischaemic changes.

Diagnosis:CVA with Acute infarct in putamen,globus pallidus on RT side 

With Hemorrhagic transformation Hypertensive urgency with

 K/C/O HTN since 2 years.

Treatment:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

3.TAB.TELMA-H PO OD

 Day 1:

S- C/O Giddiness reduced compared to yesterday

 C/O Generalized weakness

O-O/E: Pt-C/C/C

Temp:Afebrile

PR:84bpm

BP:160/100 mm of hg

RR:18cpm

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard

P/A:Soft,non tender

CNS: 

E4V5M6

          TONE   UL           LL

          Right   Normal    Normal

          Left     Normal    Normal

          POWER   UL         LL

           Right.    4/5       4/5

           Left        4/5      4/5

           

        REFLEXES RIGHT  LEFT

              B.             +          + 

              T              +          +

              S              +          +

              K              +         +

              A              +         +

              P          Flexion    Flexion

              

A:  CVA with Acute infarct in  putamen,globus pallidus on RT side 

with Hemorrhagic transformation Hypertensive urgency with

 K/C/O HTN since 2 years

P:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

3.TAB.TELMA-H PO OD

48 yr old male patient

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

CKD ward:

 48 year old man 

With DM type 2 diagnosed 10 years back 

3 years back - He had lower back ache for which he used NSAIDs, for which he visited a hospital where he was told to have multiple renal cysts 

And he was even diagnosed with hypertension then 

At that point his serum creatinine was 1.2mg/dl. He was stated on conservative treatment. He was on followup.

Post COVID, he didn't pay a visit for followups 

3 months back he developed bilateral lower edema 

Sudden onset dyspnea 

On visiting the hospital, his serum creatinine also was found to be 9mg/dl 

Since then he has been on regular Hemodialysis

Hopi:

Pt was apparently assymptomatic 20 yrs back then he developed lower back pain for which he visited to hospital and diagnosed with renal calculi for which he used medication for 3 years and underwent sx later ,still his lower back pain didn't subcided so he visited to some rmp and used NSAIDS for 10-15 years ,later on 3 years back one day he developed bilateral pedal edema with sob he visited to hospital and diagnosed with CKD and HTN and using regular medication with regular followup due covid 19 lockdown he didn't had regular checkups using medication ,3 months back when he visited to hospital then he was told to have high creatinine (around 11 ,acc to patient) and need for dialysis intervention ,then he was started on dialysis .

He had 2 sessions of dialysis every week 

Vitals at the time of admission: 

Temp-98.5

PR-92bpm

RR-26cpm

BP-130/70 mmHg

Spo2-93@ RA 

CVS- S1S2 heard 

RS- dyspnea present

     

P/A- soft,non tender 

CNS- NAD 

Diagnosis: CKD 2° ? NSAIDS ,

        DM since 12 yrs ,HTN since 3 yrs 

Complains currently- (4/1/22)

Chills and fever post hemodialysis since the past 1 month 

1 Session HD done yesterday

Soap notes 5/1/22

S

C/O chills 

O

Temp- afebrile 

BP- 150/90 mmHg 

PR- 91 BPM 

CVS - S1S2 heard 

RS- BAE + 

CNS - NAD 

P/A - soft,NT 

A

CKD 2° ?NSAID abuse 

 HTN since 3 yrs 

DM since 12 yrs 

Tab Nicardia 10 MG PO/OD 

Tab Nodosis 500 MG PO/BD 

Tab Arkamine 0.1 mg PO/TID 

Tab Orofer xt PO/OD 

Tab SHELCAL PO/OD 

Tab Pantop PO/OD

Tab Dolo 650 mg PO/ TID

 Hemogram

Hb- 5.9 mg /dl 

TLC-11000

RFT

Ur -79

Cr-6.5

UA-7.5 

CUE - 

Alb- 1+ 

Sugar - trace 

SOAP NOTES 6/1/22

S

C/O tightness of abdomen since 5 days 

O

Temp- afebrile 

BP- 150/90 mmHg 

PR- 91 BPM 

CVS - S1S2 heard 

RS- BAE + 

CNS - NAD 

P/A - soft,NT 

A

CKD 2° ? NSAID ?DM SINCE 12 YEARS 

HTN SINCE 3 YEARS  

 

P 

Tab Nicardia 10 MG PO/OD 

Tab Nodosis 500 MG PO/BD 

Tab Arkamine 0.1 mg PO/TID 

Tab Orofer xt PO/OD 

Tab SHELCAL PO/OD 

Tab Pantop PO/OD

Tab Dolo 650 mg PO/ TID

SOAP NOTES (8/1/22)

S

C/O tightness of abdomen 

1 episode of fever spike @4 am 

O 

Temp- afebrile 

BP- 140/100 mmHg 

PR- 90 BPM 

CVS - S1S2 heard 

RS- BAE + 

CNS - NAD 

 

A

CKD 2° ? NSAID ?DM SINCE 12 YEARS 

HTN SINCE 3 YEARS  

 

P 

Tab Nicardia 10 MG PO/OD 

Tab Nodosis 500 MG PO/BD 

Tab Arkamine 0.1 mg PO/TID 

Tab Orofer xt PO/OD 

Tab SHELCAL PO/OD 

Tab Pantop PO/OD

Tab Dolo 650 mg PO/ TID Tab kinpride 1mg PO/BD Tab Rantac 150 mg PO/ BD

Reports : 24/12/21